HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Luis A. Mispireta John A. Walsh Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Dumanian, G. A. Articles by Wilgis, E.F. S. Search for Related Content PubMed PubMed Citation Articles by Dumanian, G. A. Articles by Wilgis, E.F. S.

Ann Thorac Surg 1998;65:1284-1287
© 1998 The Society of Thoracic Surgeons

Radial Artery Use in Bypass Grafting Does Not Change Digital Blood Flow or Hand Function

^a Raymond Curtis Hand Center, The Union Memorial Hospital, Baltimore, Maryland, USA
^b Division of Cardiothoracic Surgery, The Union Memorial Hospital, Baltimore, Maryland, USA

Accepted for publication December 12, 1997.

Address reprint requests to Dr Dumanian, Division of Plastic and Reconstructive Surgery, Northwestern University Medical School, 707 N. Fairbanks Ct, Suite 811, Chicago, IL 60611

	Abstract

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Background. Patient selection criteria have not been clearly established for use of the radial artery as a bypass conduit. To help establish such criteria, we measured changes in digital blood flow and hand function after radial artery removal.

Methods. Ninety-eight patients of the first 122 consecutive patients considered for radial artery harvest met predetermined criteria by vascular noninvasive studies to undergo removal of the radial artery. In 42 of these 98 patients, the radial artery was actually used as a bypass conduit; 28 of these 42 patients returned for noninvasive vascular studies, a critical review of hand function, and a hand symptom questionnaire.

Results. There were no significant differences between the operated and nonoperated hands for digital–brachial indices, cold response, grip or pinch strength, digital two-point discrimination, or nine-hole peg tests. The patients had an increased incidence of a small amount of forearm numbness and tingling, but no increase of pain or cold intolerance.

Conclusions. For properly selected patients, there are minimal changes in hand function after radial artery removal.

	Introduction

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

 
The radial artery has recently been advocated as an alternative to the saphenous vein for coronary artery bypass grafting because of the high patency rates and superior flow characteristics [1]. Concern that removal of the radial artery may deleteriously effect hand function has led some surgeons to avoid bilateral removal of the radial artery. Other surgeons have preferred to use the radial artery only from the nondominant arm of patients, so that if radial artery removal were to affect hand function, the dominant arm would be spared [2].

Establishment of the safety of radial artery removal is important because of the increased use of this artery as a bypass conduit in elective procedures. Previous studies dealing with the loss of arterial inflow to the hand have centered on young trauma patients [3] and patients requiring reconstructive procedures with a free microvascular radial forearm flap [4]. Despite this concern over hand blood flow and hand function after radial artery removal, there are few guidelines for the preoperative selection of patients.

Removal of the radial artery would necessitate adequate ulnar artery blood flow to the hand to prevent symptoms of hand and digital ischemia. The standard examination for the adequacy of ulnar blood flow to the hand is the Allen’s test. Unfortunately, this test is subjective, observer dependent, and there is no "print-out" of the results of the test. Other tests to determine the importance of radial artery blood flow to the hand are either difficult for one examiner to perform [5] or require expensive equipment [6].

The vascular upper extremity noninvasive studies of 289 consecutive cardiac patients undergoing operation at The Union Memorial Hospital were reviewed. Compression of the radial artery at the wrist (simulating radial artery removal) was found to cause a significantly greater decrease in digital plethysmography pulse–volume recordings (PVRs) of the thumb, index, and fifth finger than did ulnar artery compression. Twenty-eight percent of the thumbs tested had a complete acute cessation of pulsatile blood flow with radial artery compression. In 9% of patients, both hands were so markedly radial dominant that there was a complete cessation of pulsatile digital blood flow with radial artery compression. Patients in whom the radial artery was not deemed important to maintain pulsatile blood flow were considered candidates for radial artery removal. The first 42 patients who underwent radial artery removal were invited to return for a hand reevaluation to assess the effectiveness of the patient selection protocol in the prevention of postoperative hand ischemia. The patients were also studied to determine whether there were any measurable changes of hand function attributable to removal of the radial artery.

	Material and methods

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

 
From December 1994 until December 1995, 122 patients were judged by their cardiac surgeons (L.M. and J.W.) to be potential candidates for use of the radial artery as a bypass conduit. All of these patients were sent to the noninvasive vascular laboratory for investigation of the upper arm arterial circulation. Allen’s tests were not performed as part of a "preselection" evaluation of patients. In the vascular laboratory, digital–brachial indices (DBI) of the index and fifth finger were performed. Pulse–volume recordings of the index finger and fifth finger were taken with and without compression of the radial artery at the wrist—a test done to simulate the blood flow to the hand after radial artery removal [7]. Adequacy of radial artery compression at the wrist was confirmed by noting a complete cessation of pulsatile blood flow to the digits with radial and ulnar artery compression at the wrist. A percentage of the radial artery contribution to pulsatile blood flow to the digits was calculated by dividing the surface area under the PVR curve with radial artery compression by the surface area for the same digit (same digital cuff, same inflation parameters, and same machine gain) without compression of the radial artery at the wrist. This calculation is referred to as the PVR ratio, and represents the acute change in pulsatile blood flow to a digit due to compression of either the radial or ulnar arteries (Fig 1). The thumb, index, and fifth fingers acted quite similarly to radial artery compression, with greater changes due to radial artery than to ulnar artery compression (Fig 2).

View larger version (24K): [in this window] [in a new window]   Fig 1. Calculation of pulse–volume recording (PVR) ratio. (Top) Appearance of PVR curve with and without compression of the radial artery. (Middle) Representation of surface areas. (Bottom) Normalization of surface area of PVR tracing without a radial artery contribution by the surface area of the PVR tracing with the radial artery open.

View larger version (33K): [in this window] [in a new window]   Fig 2. Data from a larger study of 289 cardiac surgical patients: pulse–volume recording (PVR) ratios from 578 index fingers with radial artery compression and with ulnar artery compression. A greater change is noted with radial than with ulnar artery compression, showing the radial dominance of digital blood flow. Distributions were similar for thumb and fifth finger (data not shown).

Forty-two of these remaining 98 patients underwent removal of the radial artery for use as a vascular conduit. The decision to use the radial artery was made solely by the cardiac surgical team after evaluation of the vascular noninvasive studies and intraoperative considerations. The radial artery was removed with its accompanying veins and surrounding soft tissue from just distal to the radial recurrent artery to the elbow to just proximal to the superficial palmar branch of the radial artery [8]. The charts of these 42 patients were reviewed, and all of these patients were invited back for repeat noninvasive vascular studies and evaluation of hand function by an occupational therapist. Thirty-two patients responded to a questionnaire regarding their subjective assessment of both hands for cold intolerance, pain, numbness, and hand function (modified from Levine and colleagues [9]). Twenty-eight patients returned for repeat hand function and blood flow tests. A stipend was paid to cover time and travel expenses. Follow-up ranged from 5 to 17 months. The protocol for this study was approved by the institutional review board of the hospital. Informed consent was obtained from all study participants.

The 28 patients who returned for repeat examination first underwent cold-stress testing of their operated and nonoperated sides. The PVR tracings were taken at 1 and 5 minutes after immersion in 15°C water for 3 minutes, and compared in terms of surface area to preimmersion values [10]. After the hands had rewarmed, standard measures for grip and pinch strength using calibrated dynamometers were taken three times, averaged, and were then normalized for age and hand dominance. Two-point static discrimination of the 5 digits was measured using a discriminator. A standard 9-hole peg test was measured for each hand in seconds and normalized for age and hand dominance.

The data were compared using paired t tests and analyzed using the INSTAT2 computer program (GraphPad Software, San Diego, CA). For the subjective questions, paired nonparametric t tests compared the operated to the nonoperated hand. When multiple comparisons were required, data were entered into an analysis of variance. Bonferroni multiple comparisons test corrections for the standard statistical significance factor of p less than 0.05 were made for all posttests.

	Results

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

 
There were no statistically significant differences between the operated and the nonoperated hands for either the vascular noninvasive studies or the tests of hand function (Table 1). Postoperative DBI were not statistically different between operated and nonoperated hands for either the index or the fifth finger. However, postoperative DBI for the index finger and the fifth finger were statistically lower in comparison with preoperative values for both the operated and the nonoperated sides. Cold-stress tests did not elicit any statistically significant differences between the arms. However, with the relatively large standard deviations present for the cold-stress tests, the sample size of 28 arms in each group for comparison would have been only able to detect a 30% difference between group means at the 0.05 confidence level. Therefore, a type II error cannot be excluded for the cold-stress data. For the subjective questions, the only statistical differences between sides were that patients noted a small area of distal forearm numbness and tingling.

	Comment

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

Digital plethysmography was used to determine preoperatively which hand was critically supplied for blood flow by the radial artery. The PVR studies were painless, quick, produced a print-out of results, and required only one person to administer. Measurement of digital blood pressure with a Doppler probe with and without compression of the radial artery was not done in this study, because of the requirement for two vascular technologists to be present to perform the study. Digital plethysmography displayed the wide variation in importance of blood flow to the digits as supplied by the radial artery. For this study, only patients with mild radial dominance defined as a maintenance of at least 40% of the area under the baseline PVR tracing were considered for radial artery removal. Maintenance of pulsatile blood flow is an important concept, because it has been shown to correlate with normal cellular function such as rates of wound healing and absence of ischemic necrosis [16].

The radial artery was removed from this carefully selected population of cardiac patients undergoing operation without major changes in measurable hand blood flow or hand function. Comparison of the DBIs and cold-stress tests between sides did not reveal any significant differences. Interestingly, postoperative DBIs for both hands were significantly lower than preoperative DBIs for both hands. This may relate to the heightened sympathetic tone of the patients in the few days before operation when preoperative noninvasive studies were performed, and it may also relate to postoperative medications, which affected vascular tone. Subjectively, the patients related a small area of tingling and numbness in the distal forearm.

This study was a "snapshot" of subsequent patient effects of use of the radial artery as a conduit—no attempt was made to catalog all postoperative symptoms or complaints generated from this upper extremity procedure. At least 2 patients of the original 42 (who did not return for repeat testing) were seen at the Curtis Hand Center for wrist flexor tendonitis within 3 months after operation.

Approximately 23% of the study patients were not deemed candidates for elective radial artery harvest due to bilateral PVR trace flattening, and perhaps too many patients were excluded from consideration considering the relatively few cases of documented hand ischemia from radial artery use. The PVR tracings in this study measured acute changes in pulsatile blood flow. With time, an acutely flattened waveform may improve over time with increased ulnar blood flow [6].

This study did not attempt to assess the suitability of the marginal candidate with moderately but not severely affected PVR tracings (a PVR ratio between 0.1 and 0.4). The patients who have no alternative conduit available and have PVR ratios in this range would be a suitable study cohort to evaluate changes in hand blood flow after removal of a radial artery deemed important to hand blood flow.

	Acknowledgments

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

 
We thank Ms Jane Buehner, Ms Cherry Koontz, and Ms Susan Dumler for their assistance in completion of this study.

	Footnotes

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

 
This article has been selected for the open discussion forum on the STS Web site: http://www.sts.org/annals

	References

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

 

1. Chen A.H., Nakao T., Brodman R.F., et al. Early postoperative angiographic assessment of radial artery grafts used for coronary artery bypass grafting. J Thorac Cardiovasc Surg 1996;111:1208-1212.[Abstract/Free Full Text]
2. Manasse E., Sperti G., Suma H., et al. Use of the radial artery for myocardial revascularization. Ann Thorac Surg 1996;62:1076-1083.[Abstract/Free Full Text]
3. Gelberman R.H., Blasingame J.P., Fronek A., Dimick M.P. Forearm arterial injuries. J Hand Surg [Am] 1979;4:401-408.[Medline]
4. Suominen S., Ahovuo J., Asko-Seljavaara S. Donor site morbidity of radial forearm flaps. Scand J Plast Reconstr Surg Hand Surg 1996;30:57-61.[Medline]
5. Husum B., Palm T. Arterial dominance in the hand. Br J Anaesth 1978;50:913-916.[Abstract/Free Full Text]
6. Pola P., Serricchio M., Flore R., Manasse E., Favuzzi A., Possati G.F. Safe removal of the radial artery for myocardial revascularization: a Doppler study to prevent ischemic complications to the hand. J Thorac Cardiovasc Surg 1996;112:737-744.[Abstract/Free Full Text]
7. Ryan J.F., Raines J., Dalton B.C., Mathieu A. Arterial dynamics of radial artery cannulation. Anesth Analg 1973;52:1017-1025.[Free Full Text]
8. Reyes A.T., Frame R., Brodman R.F. Technique for harvesting the radial artery as a coronary artery bypass graft. Ann Thorac Surg 1995;59:118-126.[Abstract/Free Full Text]
9. Levine D.W., Simmons B.P., Koris M.J., et al. A self-administered questionnaire for the assessment of severity of symptoms and functional status in carpal tunnel syndrome. J Bone Joint Surg Am 1993;75:1585-1592.[Abstract/Free Full Text]
10. Buehner J.W., Koontz C.L. The examination in the vascular laboratory. Hand Clin 1993;9:5-11.[Medline]
11. Meland N.B., Core G.B., Hoverman V.R. The radial forearm flap donor site: should we vein graft the artery? A comparative study. Plast Reconstr Surg 1993;91:865-870.[Medline]
12. Jones B.M., O’Brien C.J. Acute ischaemia of the hand resulting from elevation of a radial forearm flap. Br J Plast Surg 1985;38:396-397.[Medline]
13. Lee K.L., Miller J.G., Laitung G. Hand ischaemia following radial artery cannulation. J Hand Surg [Br] 1995;20:493-495.[Medline]
14. Boorman J.G., Brown J.A., Sykes P.J. Morbidity in the forearm flap donor arm. Br J Plast Surg 1987;40:207-212.[Medline]
15. Timmons M.J., Missotten F.E.M., Poole M.D., Davies D.M. Complications of radial forearm flap donor sites. Br J Plast Surg 1986;39:176-178.[Medline]
16. Gibbons G.W., Wheelock F.C., Hoar C.S., Rowbotham J.L., Siembieda C. Predicting success of forefoot amputations in diabetics by noninvasive testing. Arch Surg 1979;114:1034-1036.[Abstract/Free Full Text]

This article has been cited by other articles:

				M. Brzezinski, T. Luisetti, and M. J. London Radial Artery Cannulation: A Comprehensive Review of Recent Anatomic and Physiologic Investigations Anesth. Analg., December 1, 2009; 109(6): 1763 - 1781. [Abstract] [Full Text] [PDF]

				L. Jaworski, P. Siondalski, K. Jarmoszewicz, and J. Rogowski Arm temperature distribution in thermographic pictures after radial artery harvesting for coronary bypass operation Interactive CardioVascular and Thoracic Surgery, October 1, 2007; 6(5): 598 - 602. [Abstract] [Full Text] [PDF]

				S. S. Shah, J. R. Sadaba, T. J.P. Batchelor, P. Coughlin, M. T. Burniston, M. Barnfield, and C. M. Munsch Tissue perfusion in non-donor and donor forearm/hand after radial artery harvest: 1- and 5-year follow-up Interactive CardioVascular and Thoracic Surgery, August 1, 2006; 5(4): 353 - 355. [Abstract] [Full Text] [PDF]

				L. R. Sajja, G. Mannam, N. R. Pantula, and S. Sompalli Role of Radial Artery Graft in Coronary Artery Bypass Grafting Ann. Thorac. Surg., June 1, 2005; 79(6): 2180 - 2188. [Abstract] [Full Text] [PDF]

				H.-S. Lee, Y. J. Heo, and B.-C. Chang Long-term digital blood flow after radial artery harvesting for coronary artery bypass grafting Eur. J. Cardiothorac. Surg., January 1, 2005; 27(1): 99 - 103. [Abstract] [Full Text] [PDF]

				H.-S. Lee, B.-C. Chang, and Y. J. Heo Digital blood flow after radial artery harvest for coronary artery bypass grafting Ann. Thorac. Surg., June 1, 2004; 77(6): 2071 - 2074. [Abstract] [Full Text] [PDF]

				H. V. Riekkinen, K. O. Karkola, and A. Kankainen The radial artery is larger than the ulnar Ann. Thorac. Surg., March 1, 2003; 75(3): 882 - 884. [Abstract] [Full Text] [PDF]

				R. F. Brodman, L. E. Hirsh, and R. Frame Effect of radial artery harvest on collateral forearm blood flow and digital perfusion J. Thorac. Cardiovasc. Surg., March 1, 2002; 123(3): 512 - 516. [Abstract] [Full Text] [PDF]

				D. P. Taggart, M. N. Mathur, and I. Ahmad Skeletonization of the radial artery: advantages over the pedicled technique Ann. Thorac. Surg., July 1, 2001; 72(1): 298 - 299. [Abstract] [Full Text] [PDF]

				T. A. Denton, L. Trento, M. Cohen, R. M. Kass, C. Blanche, S. Raissi, W. Cheng, G. P. Fontana, and A. Trento Radial artery harvesting for coronary bypass operations: Neurologic complications and their potential mechanisms J. Thorac. Cardiovasc. Surg., May 1, 2001; 121(5): 951 - 956. [Abstract] [Full Text] [PDF]

				E. Rodriguez, M. L. Ormont, E. H. Lambert, L. Needleman, E. J. Halpern, J. T. Diehl, R. N. Edie, and J. D. Mannion The role of preoperative radial artery ultrasound and digital plethysmography prior to coronary artery bypass grafting Eur. J. Cardiothorac. Surg., February 1, 2001; 19(2): 135 - 139. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Luis A. Mispireta John A. Walsh Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Dumanian, G. A. Articles by Wilgis, E.F. S. Search for Related Content PubMed PubMed Citation Articles by Dumanian, G. A. Articles by Wilgis, E.F. S.